NCLEX: Mark Klimek - Lecture 7 (Thyroids, Adrenals, Kid Toys, & Laminectomy)

Whenever you see the word "thyroid," change it to...

"metabolism."

What are the s/s of hyperthyroidism?

Hypermetabolism:

- Weight loss

- Increased HR

- Increased BP

- Hyper-personality

- Heat intolerance

- Exophthalmos - Seen in Graves' Disease

- "Run yourself in the Graves Disease."

What are the 3 treatments for hyperthyroidism?

- Nuke it (Radioactive iodine)

- PTU (Propylthiouracil) or "Put thyroid under"

- Thyroidectomy (surgical removal)

What are the s/s of hypocalcemia?

- Paresthesia

- Tetany

- Twitching

- Spasm

- Clonus

- Seizure

- Jitteriness,

- Tremor (all UP!)

- Chvostek

- Trousseau signs

What are the treatments of a SUBthyroidectomy?

- Do not need lifelong hormone replacement

- May need to supplement at first

- AT RISK for thyroid storm

Which type of thyroidectomy requires lifelong hormone replacement?

TOTAL thyroidectomy

Which thyroidectomy is the patient at risk for hypocalcemia? Why?

TOTAL thyroidectomy due to difficulty to spare the thyroids

What are the s/s of thyroid storm?

- Temperature of >105

- High BP

- Severe tachycardia 180-200+

- Psychotically delirious

What are the 2 steps to lowering body temperature in a thyroid storm?

FIRST: Ice packs

BEST: Cooling blanket

What are post-op risks of thyroidectomy in the first 12 hours?

-Airway due to edema

- Hemorrhage: vascular gland

What are post-op risks of thyroidectomy in the next 12-48 hours?

TOTAL: Tetany due to low calcium

SUB: Thyroid storm

What are post-op risks of thyroidectomy after 72 hours?

Infection

What are the s/s of hypothyroidism?

Hypometabolism:

- Obesity

- Low HR

- Low BP

- Flat, boring, dull

- Cold intolerant

- Academically challenged

What is myxedema?

Severe hypothyroidism presented with skin involvement

What is a myxedema coma?

MEDICAL EMERGENCY!

Severe hypothermia leading to decreased mental status, hypothermia, and other symptoms that slow function in multiple organs

What is the treatment for hypothyroidism?

Levothyroxine (Synthroid)

Take alone on an empty stomach with water... in the morning 30min-1hr before breakfast

A patient with hypothyroidism will be undergoing surgery the next morning. The physician ordered the

pt NPO at 12:00 am. Pt is on Synthroid and multivitamin pills. What should the nurse question?

Clarify the NPO order for Synthroid.

The patient needs the med to get through surgery. Otherwise, the condition may potentiate the suppressing effects of the anesthesia during surgery.

All adrenal cortex diseases start with...

"A" or "C"

What is Addison's Disease?

Hypoadrenalism (Adrenal insufficiency)

- Under secretion of steroids (They're a time bomb)

- Hyperpigmented (Very tan)

- They do NOT adapt to stress

What is Cushing's Syndrome?

"If you've got a cushy, you've got more tushy."

- Oversecretion of adrenal cortex (steroids)

What is the purpose of the stress response in an individual?

To maintain:

- A normal blood pressure to perfuse the brain and other organs

- An adequate level of glucose to feed the body

What could happen if patients with Addison's Disease cannot adapt to stress?

They will go into shock and have a hypoglycemic episode called "Addisonian crisis"

What is/are the treatment(s) for Addison's Disease?

"In Addison, you ADD-a-SONE."

- Give steroids

- Glucocorticoid drugs that end in - SONE

What are the s/s of Cushing's Syndrome?

All side effects of steroid medications

DRAW THE MOON MAN!!

- Moon face

- Has a beard (Hirsutism)

- Truncal or central obesity

- Weak arms/legs (Muscle atrophy)

- Gynecomastia

- Buffalo hump

- Retaining Na+ and H2O

- Losing K+ out the back

- Stretch marks

- HIGH SERUM GLUCOSE!! Do accu-checks q6h.

- "I'm mad I have an infection" Roid rage

- Immunosuppressed

A pt comes in with an acute exacerbation of COPD. The pt is being treated with Solu-Medrol

(methylprednilosone) IV push q8 hours to reduce the inflammation in the airway. What nursing action

needs to be taken while the pt is on the medication?

Accu-checks q6h

Patients on a steroid is like diabetes even though they aren't diabetic. So complications are even WORSE if the patient is actually diabetic.

What is/are the treatment(s) for Cushing's Syndrome?

Adrenalectomy

What happens with a bilateral adrenalectomy?

Removal of both adrenal glands means the patient now has Addison's Disease, so we have to give ADD-a-SONE to treat it.

Patient will start to look like Cushman with steroids. It will take like a year or so to look back to normal.

What are the three things to consider when selecting toys and play activities for children?

1. Is it safe?

2. Is it age appropriate?

3. Is it feasible (Doable)?

What age are small toys okay for children?

<4 NO small toys.

>4 Small toys okay.

If oxygen is in use, what toys should children avoid?

NO metal or dye-cast

What is a fomite?

A non-living object that harbors microorganisms, such as stuffed animals

What toys are good to prevent fomites?

Hard plastic toys -- they can easily be disinfected

What are the best toys for ages 0-6 months?

SENSORIMOTOR

Best toy is a musical mobile (1st) or something large and soft (2nd)

What are the best toys for ages 6-9 months?

OBJECT PERMANENCE

Best toy is to teach them cover/uncover:

Jack-in-the-box

Peek-a-boo

Something large and firm

What are the best toys for ages 9-12 months?

VOCALIZATION

Best toys are speaking or verbal: Tickle Me Elmo, Woody Cowboy

What are the best toys for ages 1-3 years?

GROSS MOTOR SKILLS

Push/pull toys

Paint

Parallel Play

What are the best toys for ages 3-6 years?

FINE MOTOR SKILLS

Finger dexterity: Draw, write, colored pencils, scissors

Work on balace: Dance, ice skate, tricycles, tumbling

Cooperative Play

HIGHLY imaginative

What are the best toys for ages 7-11 years?

CONCRETE

The 3 "Cs:"

Creative: Blank paper to draw, Legos, Transformers

Collective: Baseball cards, Barbies, Beanie babies

Competitive: Winner/losers

What are the best toys for ages 12-18 years?

PEER GROUP ASSOCIATION

Hangout with kids unless recent post-op <12 hrs, immunosuppressed, contagious

What is a laminectomy?

Surgical removal of one or more vertebrae from the spine.

Why would you perform a laminectomy?

Relieves nerve root compression

What are the s/s of nerve root compression?

The 3 "Ps"

Pain

Paresthesia

Paresis

What are the 3 different locations where laminectomy is performed?

Cervical

Thoracic

Lumbar

What is the location and most important pre-op assessment for cervical laminectomy?

DIAPHRAGM and ARMS

Assess breathing

Check function of arms/legs

What is the post-op assessment for cervical laminectomy?

Watch for pneumonia

What is the location and most important pre-op assessment for thoracic laminectomy?

GUT AND ABDOMINAL MUSCLES

Assess cough and bowels

What is the post-op assessment for thoracic laminectomy?

Pneumonia and paralytic ileus

What is the location and most important pre-op assessment for lumbar laminectomy?

BLADDER AND LEGS

Assess for urinary retention or last time patient voided or emptied

Evaluate leg functions

What is the post-op assessment for lumbar laminectomy?

Urinary retention and leg problems

What is the #1 nursing intervention for post-op laminectomy?

LOG ROLL!!

What are the rules of mobilization for patients after a laminectomy or spinal surgery?

- Do NOT dangle patients

- If needed, do it less than 10-15 mins.

- Do NOT allow patients to sit for more than 30 minutes

What post-op order would you question for a laminectomy?

Up in chair for 1 hour TID

You are caring for a pt with a lumbar oligodendrogliocytoma. What is the #1 problem?

a. Airway

b. Ileus

c. Cardiac arrhythmia

d. Urinary retention

Urinary retention

What does anterior thoracic mean?

Front though the chest to the spine

What is a laminectomy with fusion?

- Taking a bone graft from the (1) iliac crest and/or (2) spine

- Bone from the hip is taken and put in place so there's no bone-to-bone friction

What are the discharge teachings for a laminectomy?

4 temporary restrictions (6 weeks):

- Do NOT sit for >30 min

- Lie flat, log roll for 6 weeks

- Don't drive for 6 weeks

- Don't lift more than 5lbs for 6 weeks, like a gallon of milk

3 permanent restrictions:

- Do not lift by bending at waist (use knees)

- Cervical laminectomy should never be allowed to lift anything over the head

- NO horseback riding, off-trail biking, jerky amusement rides, etc.